ADA-APA Mental Health Provider Diabetes Education Program

This program has been supported by a generous grant from

Learning Objectives• Describe major challenges of living with diabetes that

may be the focus of mental health treatment

• Apply general knowledge of diabetes to mental healthcare of people with diabetes

• Discuss potential roles of mental health professionals inthe care of people with diabetes

• Integrate supportive terminology to interactions withpeople with diabetes and with other healthcare providers

Welcome to the Diabetes Mental Health Provider Education Program!

• Format of the session:– Presentations from diabetes experts

• Opportunity for brief Q&A after each segment

• Submit questions via notecard and panel will answer

– This is meant to be interactive!! Please ask questionsor pose a case study for discussion.

• You will receive an email fromprofessionaleducation@diabetes.org tocomplete the online post-test and start the 5-hour online course.

• You will also receive an email regarding thereferral directory in which you can now be apart of.

What happens after the program?

Who are you?• Diabetes is everywhere. Most people have at

least some exposure to everyday life withdiabetes.

• Please raise your hand if you:– Have family members or friends with any form of

diabetes– Have diabetes yourself (optional)– Have had patients with any form of diabetes– Don’t know anyone with diabetes and want to learn!

Who are you?• Please raise your hand if you:

– Are a psychologist– Are a social worker– Are a counselor or other mental health professional– Work in private practice– Work in a medical setting– Work in another setting (what is it?)– Have had patients with diabetes and want to refine your

practice– Have never had patients with diabetes and want to expand

to work with this population

Who are you?

• Please raise your hand if you:– Live on the West coast

– Live on the East coast

– Live in the South

– Live in the Midwest

– Live in the Southwest

– Live somewhere else – where are you from?

What is Diabetes?

What is diabetes?

• Lifelong disease affecting body’s ability to makeor use insulin.

• Diabetes causes blood glucose (blood sugar)levels to go up higher than normal. – People without diabetes have blood sugars between

approx. 70-125 mg/dL when fasting

• We refer to people living with diabetes as PWD

Insulin• Insulin is a hormone made by beta cells in

pancreas needed to convert food into energy.

• Administered via injections or infusion

• Insulin is the key that allows glucose to be used by the cells

http://www.ethoshealth.com.au/

Types of Diabetes

Type 1

• Body attacks beta cellsin pancreas

• No insulin made• Sudden onset, acute,

myriad symptoms• Requires externally

administered insulin

Type 2

• Body makes insulin butnot as effective

• Difficulty absorbingnutrients, “insulinresistance”

• Prolonged onset, oftenexperience vague orno symptoms at all

Diabetes

Gestational Diabetes

• During pregnancy• Insulin resistance causes

elevated blood sugars• Increases risk of

developing type 2 diabetes

Pre-Diabetes

• Before peopledevelop type 2 diabetes, they almost always have "prediabetes"

• Blood glucose levels that are higher than normalbut not yet high enoughto be diagnosed asdiabetes

Diagnosing DiabetesFasting Plasma Glucose (FPG)Fasting Plasma Glucose (FPG)

• Fasting for at least 8 hours before test• Dx at FPG 126 mg/dl or higher

Oral Glucose Tolerance Test (OGTT)Oral Glucose Tolerance Test (OGTT)• Checks BG before and 2 hours after drinking high glucose liquid• Dx at OGTT of 200 mg/dl or higher

Glycosylated hemoglobin A1cGlycosylated hemoglobin A1c• Measures average BG over past 2-3 months• Dx at A1c of 6.5% or higher

ADA Standards of Care, 2017

Did you know? Diabetes mellitus is derived from the Greek word diabetes meaning siphon - to pass through and the Latin word mellitus meaning honeyed or sweet.

Glad you’re not a physician in the 1800’s? (tasting urine for diagnosis)

The Rising Diabetes Epidemic: More Psychologists Are Needed to Help

Support People with Diabetes

Diabetes in U.S. – Tip of the Iceberg

Diabetes:• 30.3 million people have diabetes*• 9.4% of the US population

Diagnosed: 23.1 million peopleUndiagnosed: 7.2 million people (23.8%)

Pre-Diabetes:• 84.1 million adults aged 18+ (33.9%) • 23.1 million adults aged 65+

• Progression to diabetes 5 – 15% per year

* ~5% of PWD have Type 1

CDC’s Division of Diabetes Translation. National Diabetes Surveillance System available at http://www.cdc.gov/diabetes/statistics

Number and Percentage of U.S. Population with Diagnosed Diabetes, 1958-2013

Diabetes is Exponentially Increasing

Number of People with Diabetes (20-79 years), 2015

IDF Diabetes Atlas, 2013

Almost half of all people with diabetes live in just three countries:

ChinaIndiaUSA

IDF Diabetes Atlas, 2013

The Cost of Diabetes

Diabetes Care is Costly• Diabetes cost the U.S. more than $245 billion dollars last year

• $176 billion in direct medical costs• $69 billion in lost productivity:

• increased absenteeism• reduced productivity while at work for the employed population• reduced productivity for those not in the labor force• inability to work as a result of disease-related disability• lost productive capacity due to early mortality

• 2.3 times greater medical costs for those with diabetes• Annual U.S. medical expenditures in 2012: $13,700 per person with diabetes

• Diabetes care costs increased by 41% in 5 years and are expected to continue to rapidly escalate

ADA, Diabetes Care, 2013, 36:1033-1046Stokes & Preston, 2017

Life with 30 years with type 1 diabetes…

• 109,500 finger pricks to check bg

• $54,750 in test strips

• 18,250 injections

• 3,744 infusion set changes

• 7,800 lows

• 10,950 hours of sleep lost

• $195,000 in co-pays

Diabetes Self-Management

Insulin

BG Checks

Food Activity

DSME

DSMS

Stress Mgmt

Goals for diabetes management• American Diabetes Association has standards updated

annually for the care of PWD– Available at: https://professional.diabetes.org/content-

page/standards-medical-care-diabetes

• Two equally important goals of diabetes care are to:

– Keep blood glucose as close to the target range as possible toavoid/delay complications

– Maintain high quality of life

ADA Standards of Care, 2017

Treatment for Type 1• Glucose monitoring multiple times per day via meter

and/or continuous glucose monitor (CGM)• Insulin via syringe, pen or insulin pump multiple

times per day• Constant attention to timing, dose, and impact of

insulin• Constant attention to food, exercise and stress• Regular visits with health care providers and

screenings

Treatment for Type 2

• Lifestyle changes usually targeting weight lossinclusive of healthy food choices, increased physical activity, stress management

• Treatment may also include– BG monitoring (varying frequency)

– Medications: Pills and/or non insulin injectables

– Insulin via syringe, pen or insulin pump

Treatment for Gestational Diabetes

• Intensive blood glucose monitoring multiple times daily

• A narrow target range of BGs (95 - 120 mg/dL)

• Specific nutrition guidelines

• Specific weight gain guidelines

• Frequent contact with medical providers

• Often include insulin and/or pills

Blood Glucose and Fetal Development

• Having BG’s outside of range during pregnancy(95-120) increases risks to the fetus:– Macrosomal (newborn larger than average)

– High glucose triggers the fetus’ pancreas to makeextra insulin

– Potential for miscarriage

What does diabetes management involve?Blood Glucose

Blood Glucose (BG)

• Concentration of glucose (sugar) in blood– Many use “glucose” and “sugar” interchangeably (e.g., “I am

going to check my sugar”)

– Hyper/High

– Hypo/Low

• The general target range: 70 – 180 mg/dL

– Tailored for the individual based on their needs

Factors Affecting BGBlood sugars are complicated and multiple factors influence them. In general:

– Raises BG• Food (carbohydrates aka sugar) • Stress (hormones)• Not moving (sedentary behavior)• Physical illness (flus/viruses/etc)

– Lowers BG• Insulin (endogenous or exogenous)• Antihyperglycemic agents (pills)• Physical activity

Our current treatment methods are imperfect and don’t perfectly mimic the

pancreas

Hypoglycemia (Low Blood Glucose)• Blood glucose below

70mg/dL– Impact on functioning is a point

of additional concern

• Rapid decline can be very dangerous– Seizures, loss of consciousness– Requires immediate treatment

(fast acting carbohydrates/sugar)

• Very common – 90% experience some

hypoglycemia; ~2x per week in T1D

– 10-30% experience a severe episode 1x/year

– 282,000 ER visits for adults forhypoglycemia and diabetes (2011)

• More likely: – with longer diabetes duration– at night

Cryer PE. Hypoglycemia in Diabetes: Pathophysiology, Prevalence, and Prevention. American Diabetes Association, 2009.

Causes of Hypoglycemia/Low BG

• Too much insulin

• Exercise/physical activity within last24-48 hours

• Inconsistent meal times

• Skipping meals

• Recent dietary changes

• Alcohol consumption

• Taking oral medications incorrectly

Hypoglycemia Symptoms

Symptoms

http://glutenanddiabetes.com/2013/12/30/symptoms-hypoglycemia-hyperglycemia/

Treating Hypoglycemia

• BG below 70mg/dL, use“Rule of 15”:– Take 15 grams of fast-

acting sugar (without fat)• 3-4 glucose tabs, 4oz juice or

½ can regular soda, sugarycandies not chocolate

– Check BG again after 15 minutes

– If not >70mg/dL, repeat• Keep sugary candy, juice

in your office

• Glucagon: – Hormone used to raise BG

through the liver when aperson is unconscious or unable to respond

– Administered via injection

• People on insulin: Need to train loved ones and roommates who are around them how to use glucagon and call 911

Hyperglycemia (High Blood Glucose)

• Blood glucose >180mg/dL– >300mg/dL is point of additional concern

Treat elevated BGs with:

• Insulin

• Drink water

• Light physical activity

NOTE: PWD may say “I am high” when their BG is above their target range

Causes of Hyperglycemia

• Not enough insulin or oral diabetes medications

• Side effects from other medications• Too much food intake• Inactivity• Illness• Stress• Short- or long-term pain• Menstrual periods• Dehydration

Symptoms of Hyperglycemia

Symptoms

If seen in session, this

isn’t resistance

http://glutenanddiabetes.com/2013/12/30/symptoms-hypoglycemia-hyperglycemia/

Diabetic Ketoacidosis (DKA)• Results from exceptionally high prolonged sustained BG

– Usually due to lack of insulin

• Serious condition that can lead to coma or death.

• Treatment usually takes place in the hospital– Average length of stay 1-3 days

• PWD can help prevent it by learning the warning signsand checking urine and blood regularly.

Causes of DKA

• Not getting enough insulin• Expired or insulin that’s gone bad (heated/frozen)

Not enough insulin

• Increased insulin needs during acute illness

Illness

• Body's reaction to very high glucose levels• Can result from illness or skipping meals

Starvation ketones

Blood Glucose Monitoring

• Snapshot of currentBG level

• Goal is to balancehigh or low BGs with:– Insulin: ▼ BG– Activity: ▼ BG– Glucose/carbs: ▲ BG

• Insulin adjustmentsneed to be precise:– Carb count– Activity– Timing– Current BG and trend– Other factors

Type 1 and BG Monitoring

• Necessary to determine management behaviors (giving insulin orglucose)

• Multiple BG checks per day:

• Constant attention to timing, dose, and impact of insulin• Constant attention to and balance between food, exercise and stress to

manage glucose levels

Before and after meals

Before, during, after

activity

When illWake-up

and before bed

Sometimes overnight

Before driving

Type 2 and BG Monitoring

• Not as central to determine management behaviors

• Recommended 2 BG checks/day:

• Recommendations are not consistently applied

• Often access/insurance limitations for BG monitoring supplies

Wake-up

Before bed

Tools to Self-Monitor

Meter and Test Strips

• Device used to check BG • Blood drop goes on strip• Strip inserted into meter

to read BG level

Meter and Test Strips

• Device used to check BG • Blood drop goes on strip• Strip inserted into meter

to read BG level

Lancet

• Tiny sharp needle• Used to poke finger to

get a drop of blood to check BG

Lancet

• Tiny sharp needle• Used to poke finger to

get a drop of blood to check BG

Continuous Glucose Monitor (CGM)

• Small device worn on body, electrode inserted under skin

• Monitors glucose every 5 minutes, shows current glucose level and trend

Continuous Glucose Monitor (CGM)

• Small device worn on body, electrode inserted under skin

• Monitors glucose every 5 minutes, shows current glucose level and trend

Blood Glucose Monitoring

Steps

1. Wash hands2. Insert test strip

into meter.3. Use lancing

device on side offingertip to get a drop of blood.

4. Touch and hold edge of test strip to drop of blood

5. Wait for the result. Blood glucose level will appear on the meter's display.

Glycemic Outcomes (A1C)• The hemoglobin A1c is a blood assay that gives an estimate of

average blood sugar over the last 2-3 months.– Routinely measured in clinics for health status

– Goal: Lower A1C = lower average BG

• Frequency of A1c measurement– Type 1 diabetes: Quarterly

– Type 2 diabetes:• Twice/year when meeting treatment goals

• Quarterly when treatment is changed or not meeting goals

ADA Standards of Care, 2017

A1C Goals

• Targets can be difficult toachieve– A1C isn’t a grade

• A1C is often used by healthcare professionals as an indicator of treatment adherence…– But it’s not really!

– Lots of factors influence A1C

Adults:Adults:

Children & Adolescents:Children & Adolescents:

Seniors, Adults with Complications & Comorbidities:

Seniors, Adults with Complications & Comorbidities: <8.0%

<7.5%

<7.0%

Discuss with your neighbor

• What do you know about what it takes to achieveBG and A1C goals?

• Can diabetes be managed by eating and exercisealone?

• What are the behavioral tasks required for diabetesmanagement (type 1 and type 2)?

Answer

Type 1• Requires many self-

management behaviors. • Exogenous insulin

administration is required to sustain life.

• BG monitoring is important to know how much insulin to give.

• Diet and exercise can help influence BG levels, as well.

Type 2• Progressive condition and

it’s normal for treatment needs to change over time.

• Some people may be able to manage their blood glucose levels with diet and exercise alone.

• At some point other medications, including insulin, may be necessary.

What does diabetes management involve?Medication

Insulin

Long-Acting “Basal”

• Provides steady level ofbackground insulin throughout the day/night

• Usually administered via injection once or twice a day via syringes or pen

• Basal level of insulin also delivered via pump

Rapid-Acting “Bolus”

• Covers meals or treats high BGs

• Doses vary based on need

• Administered via injections, pens,or insulin pump

Insulin

Type 1The body doesn’t produce insulin and must be administered – total dependence on exogenous insulin• Without insulin develop acute

hyperglycemia and die within a week

• Physiologic symptoms are rapid and acute

Type 2• Due to disease progression,

many people will eventually need to take insulin in addition to medications. – Some people may be started on

insulin therapy at diagnosis to lower BG (may be taken off later)

– Insulin is often needed and may be perceived as worsening of the disease.

– Can cause hypoglycemia

Everyone without diabetes has insulin created by the body

Insulin Delivery Tools

• Syringes are used to draw insulin from vials

• Needles and pens are used to inject insulin

• Insulin Pump: Small device that holds and delivers insulin into the body continuously. Connected with a plastic tube (infusion set). Usually type 1.

• Automated Insulin Delivery: Devices worn on the bodyincorporating CGM and insulin pumps to semi-automate insulin delivery based on glucose levels. Sometimes called: closed loop & artificial pancreas. Usually type 1.

Other Medications

• OHA: Oral hypoglycemic agents

• Metformin: Most common OHA

• Injectable: Non-insulin agent delivered throughinjections

OHAs Used to Treat T2D

Different types/classes of drugs work in different ways to lower BG levels:

• Sulfonylureas

• Biguanides

• Meglitinides

• Thiazolidinediones

• DPP-4 inhibitors

• SGLT2 Inhibitors

• Alpha-glucosidase inhibitors

• Bile Acid Sequestrants

Oral combination therapy

• Drugs with different mechanisms

of action can be used together

• Can increase cost and side effects

• Can lower BG levels more than

switching out meds

• Make sure to ask patients about

potential side effects

Other Injectable Medications Besides Insulin

GLP-1 Receptor Agonists• Stimulates insulin production while suppressing the liver’s glucose output. They may

decrease appetite and promote some weight loss. Can cause hypoglycemia.

Amylin Analogue• Slows food from moving too quickly through the stomach and helps keep after-meal

glucose levels from going too high. It can suppress appetite and may cause weight loss. It also reduces glucose

Did You Know?

• Some PWD with type 1 also use non-insulin medications including Pills and/or injectables

• Most are FDA approved for type 2 only

– Can help with management or insulin resistance

– In addition to, not instead of, insulin

• Insulin is necessary for all people with type 1, no matter additional medications used

Medication Taking- why do we care?

Diabetes Time Demands

Time with Physician

Time in Self-Management

• 40% of patients say medication interferes with their ability to live a normal life

• Many patients view starting medications as a personal failure and a sign that their diabetes is getting worse

• 40-70% of PWD new to insulin will no longer be taking injections as prescribed after 12 months

• People with chronic diseases benefit the most from taking medications - and risk the most from failing to take them properly

Nicolucci et al., 2013

Medication Taking

Why Self-Management is Difficult• Treatments are very complex and demanding • Adherence does not guarantee positive results• Often little immediate positive feedback• No vacations feeling burned out• Treatments better but are still far from perfect• Effective treatments are often not prescribed• Environment discourages healthy lifestyles

• Conflicts with PWDs cultural and health beliefs

• Intergenerational context

• For youth, incongruent with developmental stage

What does diabetes management involve?Healthy Eating

Stop and Think

Do PWD need a special diet?

AnswerNo!

Fact: A healthy meal plan for people with diabetes is generally the same as a healthy diet for anyone – low in saturated and trans fat, moderate in salt and sugar, with meals based on lean protein, non-starchy vegetables, whole grains, healthy fats and fruit. Diabetic, "dietetic,” and sugar-free foods generally offer no special benefit. Most of them still raise blood glucose levels, are usually more expensive and can also have a laxative effect if they contain sugar alcohols.

Healthy Eating

• Food is a cornerstone of diabetes treatment• Certain foods increase BG levels• For everyone including PWD, it’s important to make healthy

food choices• Certain eating patterns increase obesity• Important for psychologists to support healthy food choices

Video “diabetes police”

Diabetes Plate

Many People with T2 Taught:

Carbohydrates = Carbs

• Biggest impact on blood glucose• Three main types of carbs

– (starches & sugars raise BG):

Starches (complex carbs)

Starches (complex carbs) SugarsSugars

FiberFiber

Carb Counting

Accurate carb count needed to dose insulin accurately

• Eat approximately the same amount of carbs at each meal for set insulin dose

Fixed insulin regimen

• People take a ratio of insulin to the grams of of carbs consumed.• Calculation of carb content/amount in food• Monitoring BG before food intake• Timing of insulin and food intake can affect insulin effectiveness

• Ratio may vary during different times of day.

Basal/Bolus Insulin therapy

What do you see?

PWD see this…

www.diabetesart.com

Before you can eat, determine how much insulin you need.

Start the stop-watch on your phone and follow the following dose calculation formula before eating your snack:

Current body weight minus ideal body weight over body weight ratio 1/90, rounded to the nearest tenth, plus the product of amount of fat in the snack divided by the fat ratio (Calculated by hour of day multiplied by your age), rounded to the nearest tenth. Round the tenths of this total down to 0 if below x.3, up to half if between x.4 and x.7 and up the nearest whole if x.8 or x.9.

How long did it take?What did this process feel like?

Walkamilecards.com

Try it yourself at the morning break….

What does diabetes management involve?Physical Activity

Overall Benefits of Physical Activity

• Better overall health

• Improved BG and insulinsensitivity– Can help lower BG level

• Reduced cardiovascular risk

• Weight loss (and maintenance)

• Enhanced well-being

• Prevention or delay of Type 2

Colberg et al. Diabetes Care, 2016;39(11):2065–2079

Let’s Get Moving• Physical activity

– All movement that increases energy use

• Exercise– Planned or structured physical activity at least 150

min/week

• Reducing sedentary behavior is also important– Interrupt sedentary with planned movement every 30

minutes

• All recommendations should be tailored tomeet the specific needs of each individual by the medical team

ADA Recommendations for Youth

• Engage in 60 min/day or more of moderate or vigorousintensity aerobic activity

• Incorporate vigorous, muscle-strengthening, and bone-strengthening activities as part of this time at least 3days/week

Colberg et al. Diabetes Care, 2016;39(11):2065–2079

Support Physical Activity

• Focus on:– past successes

– identify small achievable goals

– work to identify and overcome barriers to participation

– provide information

– do follow-up

– and periodically review goals

– social support and “buddying up”

Colberg et al. Diabetes Care, 2016;39(11):2065–2079

Exercise-induced hypoglycemia

Causes:• Too much insulin• Starting blood glucose level • Type of exercise – aerobic vs.

anaerobic• Duration – brief vs. sustained• Intensity – low-moderate vs.

vigorous

• Food – carbs vs. protein/fat• Delaying treatment - amount

and choice• Injection or infusion site• Time of day

Hypoglycemia can occur up to 24-48 hours after exercise

May need to reduce insulin or add carb intake after exercise, especially overnight

Review of Tasks of Diabetes Management

• Management may include:– Glucose monitoring

– Medication taking to regulate BGs (pills and/or insulin)

– Attention to dietary intake

– Attention to physical activity

– Regular health care visits and screenings

– Stress management

Diabetes Self-Management Education

Powers et al., 2017

ADA Standards of Medical Care in Diabetes recommends all patients to be assessed and referred for:

EMOTIONAL HEALTH

Mental health professional if needed

NUTRITION

Registered dietitian for medical nutrition therapy

EDUCATION

Diabetes self-management education and support

1 2 3 4

Four critical times to assess, provide and adjust diabetes self-management education and support

At diagnosis Annualassessment of education, nutrition, and emotional needs

When new complicating factors influence self-management

When transitions in care occur

Knowledge: Necessary but not Sufficient• Given the many demand of diabetes, it is important PWDs receive

diabetes self-management education (DSME) which aims to facilitate knowledge, skills, & abilities necessary for diabetes self-care.

• In studies with 3- or 6-month follow-up, DSME has been shown topositively impact:

– diabetes knowledge

– self-care behaviors

– glycemic outcomes

– emergency department visits and hospitalizations

Rui et al., 2014, CDC Morbidity and Mortality Weekly Report; Dublin, et al. DC Annals of Emergency Medicine 2009; Norris, Diabetes Care 2001

Diabetes Self-Management ServicesDiabetes Self-Management Education (DSME)Diabetes Self-Management Education (DSME)

• Classes with other PWDs and experts• Individual visits with diabetes care team (nurses, physicians,

educators, etc)• Learn diabetes basics and how to integrate into life

Diabetes Self-Management Support (DSMS)Diabetes Self-Management Support (DSMS)• Behavioral, educational, medical, or psychosocial support• Help PWD carry out and maintain self-management behaviors• This is where you fit in!

But PWDs have limited access to DSME

In the US, 54.3% of people with diabetes had ever attended a DSME class (2005)

In the US, 54.3% of people with diabetes had ever attended a DSME class (2005)

1/3 of Medicare beneficiaries use DSME or Medical Nutritional Therapy benefits

1/3 of Medicare beneficiaries use DSME or Medical Nutritional Therapy benefits

7% of adults with private insurance newly diagnosed with type 2 attended DSME within 1st year

7% of adults with private insurance newly diagnosed with type 2 attended DSME within 1st year

Those who never received DSME have a 4x increased risk of major complicationsThose who never received DSME have a 4x increased risk of major complications

54.3%

1/3

7%

4x

Complications

Diabetes Can Lead to Serious Health Complications

Microvascular

Retinopathy

Blindness

Neuropathy

Loss of sensation Gastroparesis Sexual

dysfunction

Kidney Disease

Kidney failure Dialysis

Circulatory System

Ulcers, Amputations

Diabetes

The leading cause of new cases of end stage renal

disease2

A 2- to 4-fold increase in

cardio-vascular mortality

The leading cause of new cases of

blindness in working-aged

adults

The leading cause of non-

traumatic lower extremity

amputations

Centers for Disease Control and Prevention. National Diabetes Fact Sheet, 2005.

Sexual DysfunctionWomen• BG levels may go up and down before and during a

menstrual period because of changes in hormone levels.

• Vaginal dryness twice as likely with diabetes.

• Maintaining BGs in target before getting pregnant and during pregnancy lowers chances of prematurity, having a baby that's larger than normal, and birth defects.

• Menopause:

– Many notice BGs are more variable/less predictable. BG swings can compromise sleep. Sleep deprivation can cause more fluctuations in BG.

– Menopausal symptoms can be mistaken for symptomsof low BG.

Men

- Blood vessels and nerves in the penis can become damaged resulting in erectile dysfunction.

- Twice the risk of low testosterone in men with T2D, overweight, or both

- Can affect sex drive.

Lowering A1c from 9.0% to 8.1% confers a 40% risk reduction of eye disease associated with blindness

DCCT/EDIC Writing Team, JAMA, 2002

Diabetes Can Reduce Lifespan

Morgan CL, et al. Diabetes Care. 2000;23:1103-1107.

Men

0

2

4

6

8

10

12

7.57.0

Yea

rs lo

st

Average Years Lost for People with Diabetes Compared With People without Diabetes

Women

Native Americans

Non-LatinoWhites

AsiansLatinos Non-LatinoBlacks

Total

Data for races other than white and black should be interpreted with

caution because of misreporting of race on death certificates.

Diabetes-Related Mortality Is Higher Among Minorities

Tota

l D

ea

ths

(%

)

3.02.7

4.3

5.4

3.4

5.0

0

1

2

3

4

5

6

Emotions about Complications

• Worry

• Shame– Self-blame

– Blame from loved ones

– Blame from providers

• Fatalism/hopelessness

• Denial

• Associations with family members who have died

Communicating about Diabetes

Talking about Diabetes Activity

• Break into small groups (2-3 people) and look atthe following excerpt and think about:

• What impressions does the way of speaking inthese descriptions give you?

• What suggestions do you have for modifying thelanguage in these descriptions and why?

Dr. Gomez is a PCP who refers his patient, Maria Torres, to you for therapy. Maria has type 2 diabetes and is overweight. Dr. Gomez calls you and says “Maria is one of the hardest noncompliant diabetics I’ve encountered. She never tests her sugar, eats whatever she feels like, and then is surprised and angry with me when she gains weight and has a bad A1c! What does she think is going to happen if she doesn’t diet or comply with the exercise plan I gave her? I’m hoping you can get her in line.”

Talking about Diabetes Activity

• What impressions does the way of speaking inthese descriptions give you?

• What suggestions do you have for modifying thelanguage in these descriptions and why?

What not to say• Diabetic: Use “person-first” language instead of labeling

the person by their condition.– Person/People with Diabetes (PWD) is preferred

• Brittle: Antiquated term used to describe people with alot of unpredictable glucose variability.

• Testing BG: You don’t pass or fail diabetes, and thisphrasing can be stressful.– Try “checking or monitoring BG”

What else not to say:• “Bad/Good” glucose values: Glucose values are data to help

make diabetes management decisions. The only “bad” number is the one a PWD doesn’t know– Instead use in or out of the target range

• Cheat or sneak: Implies malice and breaking of “rules” and does not recognize many reasons for health behavior choices. – Instead use choose or choice

• Diet/dieting: Loaded and often discouraging terms suggesting short-term restriction. – Instead use meal-planning or healthy eating

Adherence vs. Compliance• Adherence: the extent to which a person takes medications as

prescribed:

- Implies active collaboration in treatment

- Agreement to recommendations for therapy

• Compliance: passive following of physician’s orders (stigmatizing)

• Avoid Non-compliant and non-adherent– These terms can be patronizing and don’t recognize the complexity of

management demands or the autonomy of the individual in managing diabetes.

– Instead use self-management or medication-taking behaviors

Top 10 Most Annoying Things PWD Hear• My grandma had diabetes. She lost her leg, then she died. (Thank you, that’s

inspiring!)

• You’ll die if you eat sugar, right?

• You have diabetes? You don’t look that fat. (Gee, thanks….)

• You take insulin? Oh, you must have the bad kind of diabetes. (Really? What’s the good kind?)

• Your child has diabetes? Did they get it because you fed them too much candy?

• Oh my god, you have to take shots every day? I’d die if I had to do that. (Well, I’d die if I didn’t.)

• Doesn’t that hurt? (Um, yeah, it’s a sharp object going into my body. Duh!)

• Well, that sounds better than something like leukemia.

• Oh my god, can you eat that? You can’t eat that!

• That’s the disease that causes you to lose your legs, right?

www.diabetesdaily.com

During the break…

• Take an opportunity to check your blood glucose

• Reflect on some of the following:– What snacks would you choose if your blood glucose

was high or low?

– What self-management would be required during thisshort 15 minute break?

– How do you feel about checking your blood glucose?• What if you had to do this multiple times throughout your

typical work day?